PEDODONTICS

1. CHILD ABUSE AND NEGLECT
Dr.Sharath Chandrashekhar

2. DEFINITION
• Child abuse, as defined by Gill (1968)
“Nonaccidental physical injury, minimal or fatal, inflicted upon
children by persons caring for them.”
•WHO defines child abuse as "all forms of physical and/or
emotional ill-treatment, sexual abuse, neglect or negligent
treatment or commercial or other exploitation, resulting in
actual or potential harm to the child's health, survival,
development or dignity in the context of a relationship of
responsibility, trust or power.

3. PREVALENCE
• 2006: US dept of Health and Human Services:
– 65% of child maltreatment encompasses neglect
– 16% involves physical abuse
– 9% involves sexual abuse
– 7% involves emotional abuse
– >2% involves medical neglect
• Average age of identification of maltreatment victims: 7.4 years
• Infants -2 years : Most often victims of child neglect

4. PREVALENCE IN INDIA
• India has largest number of children in world (375 million),
nearly 40% of its population.
• 69% of Indian children are victims of physical, emotional, or
sexual abuse.
• New Delhi, has an over 83% abuse rate.
• 89% of crimes are committed by family members.
• Boys face more abuse (>72%) than girls (65%).
• More than 70% of cases go unreported and unshared even with
parents/ family.
Summary report of ‘Workshop on International Epidemiological Studies’ : XIXth
ISPCAN International Congress on Child Abuse and Neglect, Sept 2012

5. HISTORICAL BACKGROUND
• First documented and reported case occurred in 1874 with a
child named, Mary Ellen.
• Late 19th century: ‘House of Refuge’ movement (safe place for
abandoned children)
• 1870s: New York society for Prevention of Cruelty to Children
established to work in coherence with “House of Refuge”
• 1946: Medical discovery of child abuse was documented by
Caffey on observing children with multiple bone fractures and
children with trauma unsubstantiated by parents.

6. •1962: Term ‘Battered child syndrome’ by Henry Kempe
• 1972: Kempe founded ‘Kempe Centre’
• 1974: Child Abuse Prevention and Treatment Act
• 1978: Mclain: coined CHILD ABUSE AND NEGLECT

8. PREDISPOSING FACTORS
PARENTAL CHARACTERSTICS
CHILD CHARACTERSTICS
ENVIROMENTAL CHARACTERSTICS

9. PARENTAL CHARACTERSTICS
• Violence
• Poverty
• Parental history of abuse
• Socially isolated
• Low self esteem
• Less adequate maternal functioning.

10. CHILD CHARACTERSTICS
• Unwanted or unplanned child
• No. of children in the family
• Child's temperament
• Position in the family
• Additional physical needs if ill or disabled
• Activity level or degree of sensitivity to parental needs.

11. ENVIRONMENTAL CHARACTERISTICS
• Chronic stress
• Problem of divorce
• Poverty
• Unemployment
• Poor housing
• Frequent relocation
• Alcoholism
• Drug addiction.

13. PHYSICAL ABUSE
• Physical abuse according to WHO is that which results in potential
harm from an interaction and lack of interaction which is reasonable
within the control of parent or person in a position of responsibility,
power and trust.
• Forms of Physical Abuse
• Female infanticide
• Battering of the child
• Murder of the child
• Branding or body piercing
• Child labor
• Abandonment of the child.

15. IDENTIFYING PHYSICAL ABUSE IN
CHILDREN
• Often, abuse stems from an angry response of caretaker to
punish the child for misbehaviour.
• Most commonly recognized by clinical findings, but history is a
helpful tool when child reports with non-descriptive findings.
• Identifying factors elucidated in history and clinical
examination.

16. HISTORY
• Correct questions to be asked.
• Eyewitness history:
– Child states that injury is caused by parent.
– Parent accepts that one of many injuries is caused by
him but not all.
– One parent accuses the other about injury.
• Unexplained injury
– Denial
– Vague explanation
– No explanation
– Inconsistent explanation
– Alleged self-inflicted injury
• Delay in seeking medical care

17. CLINICAL FINDINGS
• BRUISES
• MARKS
• BURNS
• LACERATIONS AND ABRASIONS
• FRACTURES AND DISLOCATIONS
• MUTILATION INJURIES

18. MARKS
• HUMAN HAND MARKS:
– Grab mark: oval shaped mark that resembles fingerprints due to
holding of child in violent shaking.
– Important to differentiate from non-abusive marks like when the
parent holds the child’s legs to help him walk or on the cheeks,
when an adult squeezes it in an attempt to feed food or medicine.

19. • STRAP MARKS:
– 1-2 inches wide, sharp-bordered, rectangular bruises of various
lengths.
– Caused by a belt.
• LASH MARKS:
– Narrow, straight edged bruises or scratches caused by thrashing
with tree branch or stick.

20. • LOOP MARKS: – Secondary to being struck with a doubled
over lampcord , rope or fan-belt. – The distal end of the loop
strikes with maximum force and leaves loop shaped scars.
• GAG MARKS: – Abrasions near corner of mouth.
• BIZARRE MARKS: – Blunt instrument is used in punishment.
– Marks resembles the inflicting instrument in shape.

21. • CIRCUMFERENTIAL TIE MARKS:
– On ankles or wrists when a child is restrained.
– Narrow rope/ cord: circumferential cut
– Wide/ broad strap of cloth : friction burn or rope burn that
encircles the extremity.

22. BRUISES
• Sites for inflicted bruises:
– Lower back and buttocks (Patting)
– Genitals and inner thighs
– Cheek (slap marks)
– Ear lobe (pinching)
– Upper lip and frenum (forced feeding)
– Neck (Choke marks)

23. BURN INJURIES IN CHILD ABUSE
• Two general patterns:
• Immersion
 Child falling or being placed into a tub or other container of
hot liquid.
 In a deliberate burn, depth of the burn is uniform.
 Clear line of demarcation
 Deep injuries to buttocks and genital area.

25. FRACTURES
• Are diagnosed in up to third of children who have been investigated
for physical abuse.
•Often occult fractures.
•80 % of all fractures from abuse are seen in children under 18 months.
(Merten et al)
•A child with rib fractures has a 7 in 10 chance of having been abused.
•

26. • Mid-shaft fractures of humerus are more common in abuse
than in nonabuse children.
• Commonly seen
-Ribs
-Skull
-Long bones
Merten DF, Radlowski MA, Leónidas JC. The abused child: a
radiological reappraisal. Radiology 19S3;1A6:377-S'I Feldman
i<W, Brewer DK. Child abuse, cardiopulmonaiy resuscitation and
rib fractures. Pediatrics 198'i;73:339-42.,

27. BITE MARKS
• Defined as (Clark 1992) “a pattern produced by human or
animal dentitions and associated structures in any substance
capable of being marked by these means.”
• Gall et al (2003) classified bite marks as example of ‘crush
injury’ , where each tooth compresses the skin and soft tissues,
crushing them.
• Epidemiology:
•Knight (1996), Mason (2000): relatively common and most
commonly in context of sexually motivated assault.

28. • Recognition:
•Human bite marks may present as diffuse or specific bruising,
abrasions or lacerations to complete avulsion of the tissue.
•Comprise of two opposing (facing) U shaped arches separated by open
spaces.
•Central bruising, an area of hemorrhage, representing a ‘suck’ or
‘thrust’ mark is often present: caused by compression of soft tissues
between the teeth.
•Imprinting by palatal/ lingual surfaces of teeth may be present.

30. ORAL MANIFESTATIONS OF CAN:
Physical abuse
•Lips:
•bruises
•lacerations
•scars from persistent trauma,
•burns caused by hot food or cigarettes
•Bruising, scarring or erosion at corners of mouth (gag trauma)
•Mouth:
•Tears of labial or lingual frenum caused by either a blow to the mouth,
forced feeding or forced oral sex,
•Burns or lacerations of gingiva, tongue, palate or floor of the mouth
caused by hot utensils of food.

31. •Teeth:
•Fractured
•Displaced
•Mobile
•Avulsed,
•Nonvital and darkened,
•Multiple residual roots with no plausible history to account for
the injuries,
•Unaccountable malocclusion.
•Maxilla/ Mandible:
•Signs of past or present fracture of bones, condyles, ramus or symphysis
•Unusual malocclusion resulting from previous trauma.

32. SHAKEN BABY SYNDROME
• Also called:
-Slam syndrome
-Shaken-impact syndrome
• John Caffey, a pediatric radiologist popularized term ‘whiplash
shaken baby syndrome’ in 1972, to describe a constellation of
clinical findings in infants that included:
• Retinal hemorrhages,
• Subdural and/or subarachnoid hemorrhages
• External cranial trauma.

33. • Serious form of child maltreatment most often involving
children younger than 2 years but may be seen in children upto
5 years.
• Etiology:
•Act of violent shaking that leads to serious or fatal injuries.
•Generally results from tension and frustration generated by a
baby’s crying or irritability

34. Clinical features:
•Signs may vary from mild and non-specific to severe.
• Non-specific signs:
-Moderate ocular or cerebral trauma
-History of poor feeding, vomiting, lethargy and/or
irritability occurring for days or weeks.
• Non-specific signs are sometimes attributed to viral illness,
feeding dysfunction and colic.

35. Battered-child syndrome
• (Henry Kempe, 1962) A clinical condition in young
children, usually under 3 years of age who have received
non accidental wholly in excusable violence or injury, on
one or more occasions, including minimal as well as
severe fatal trauma, for what is often the most trivial
provocation, by the hand of an adult in a position of trust,
generally a parent, guardian or foster parent.
• (Sewyn, 1985) Is a child who shows clinical or
radiographic evidence of lesions that are frequently
multiple and involve mainly the head, soft tissue, the long
bones, and the thoracic cage and that cannot be unequally
explained.

36. • FEATURES
• Multiple bruising over entire body,
• Different colour shadow- different dates of origin
• Facial scaring, burns, bite marks
• Fractured/Missing teeth.
• Radiographic evidence – previous injury
• Repairing fracture lines of skull, mandible, limb

37. SEXUAL ABUSE
• Gravest form of abuse where most of children are bearing it silently
and suffering their entire life
• 53.22% have been reported to suffer from some form of sexual
abuse where 52.94% are boys and 47.06% are girls.
• It involves an inappropriate sexual behavior that includes reaching
out to
-child genitals/ getting them to touch genitals of adults,
-indecent/vulgar language,
-use of appropriate words, rape, exhibitionism or sexual
explanation with/without touching them, done by a
stranger/caretaker/babysitter/teacher/parent.

38. Suspect Sexual Abuse When the Child
• Has difficulty in walking or sitting.
• Reluctant to expose his body over-clothe to hide scars, full-
length sleeves in hot weather.
• Reports nightmares or bed-wetting.
• Experiences a sudden change in appetite.
• Demonstrates bizarre, sophisticated or unusual sexual
knowledge or behavior not appropriate for his age.
• Becomes pregnant or contracts a venereal disease, particularly
if under age 14 years.
• Runs away
• Reports sexual abuse by a parent or another adult caregiver

39. • Suspect Sexual Abuse
• When the Parent Is over protective about the child.
• Limits his contacts with other people, specially opposite sex.
• Is jealous of other people interacting with the child.
• Secretive about the child.

40. EMOTIONALABUSE
•It is maltreatment which results in impaired psychological growth and
development.
•Involves words, actions and indifference.
•Examples:
•Verbal abuse,
•Excessive demands on a child’s performance,
•Discouraging caregiver and child attachment,
•Penalizing a child for positive, normal behaviour.
•Overlaps with physical abuse.
Garbarino, J. & Garbarino, A. Emotional Maltreatment of Children. (Chicago,
National Committee to Prevent Child Abuse, 2nd Ed. 1994).

41. EMOTIONALABUSE: Etiology
•Stressful life of parents
•Reduced capacity to understand children
•Alcoholism
•Drug abuse
•Psychopathology
•Mental retardation
•Controlling personality of parents
•Family stress
•Unemployment
•Poverty
•Isolation
•Divorce
•Death of spouse
A single factor may not lead to abuse, but in combination they can create
social and emotional pressures that lead to emotional abuse.

42. CHILD NEGLECT
•Inattention to basic needs of a child: food, clothing, shelter, medical
care, education and supervision.
•Definition: by AAPD -“willful failure of parent or guardian to seek
and follow through with treatment necessary to ensure a level of oral
health essential for adequate function and freedom from pain and
infection.”
•Types:
•Physical
•Medical
•Inadequate supervision
•Educational
•Emotional

44. Dental Neglect
• Dental neglect is willful failure of parent or guardian to seek and
follow through with treatment necessary to ensure a level of oral
heath essential for adequate function and freedom from pain and
infection.
• Dental caries, periodontal diseases, and other oral conditions, if left
untreated, can lead to pain, infection, and loss of function.
• These undesirable outcomes can adversely affect learning,
communication, nutrition, and other activities necessary for normal
growth and development.

45. ORAL MANIFESTATIONS OF CAN:
Dental Neglect
•Untreated rampant caries,
•Untreated pain, infection, bleeding or trauma affecting
ofofacial region
•History of lack of continuity of care in the presence of
identified dental pathology.

46. MUNCHAUSEN SYNDROME BY PROXY
• “Munchausen syndrome’ described by British physician,
Richard Asher in 1951.
•Munchausen syndrome by proxy: term coined by Roy Meadow
in 1977.
•Referred to as ‘illness induction syndrome’ and ‘pediatric
symptom falsification’
•Findings:
•Fabrication of subjective symptoms
•Self-inflicted conditions
•Exaggeration of pre-existing medical disorders.

47. • Strange combination of physical abuse, medical neglect and psychological
that occurs with active involvement of medical profession.
• Carter et al - An often misdiagnosed form of child abuse in which a parent
or caregiver, usually mother, intentionally creates or feigns an illness in
order to keep child in prolonged contact with health providers.
• Perpetrators systematically misrepresent symptoms, fabricate signs,
manipulate laboratory tests or even purposefully harm child.
• Goal is to create symptoms or induce illness so that child will receive
unnecessary and potentially harmful medical care.
Carter KE, Izsak E, Marlow J. Munchausen syndrome by proxy caused by ipecac
poisoning. Pediatr Emerg Care. 2006;22(9):655-656.

48. Severity

49. Methods of inducing illness
Laura Criddle. Monsters in the closet:
Munchausen Syndrome by Proxy. Critical Care
Nurse 2010;30(6):46-55

50. IDENTIFICATION OF CAN
• Doctors of Medicine are expected to practice 4 Rs
– Recognize
– Record
– Report
– Refer
• Clinician should be able to recognize the specificities of oral
and dental status, since it could be the first indications of
abuse.
Kenney JP. Domestic violence: a complex health care issue for
dentistry today. Forensic Sci Int. 2006 May 15;159 Suppl
1:S121-5.

51. • The prevention and diagnosis of child abuse is usually
undertaken by a Paediatrician. The dental team has an
important role to play however as the head and neck are
the areas most often targeted.
• First indication usually comes during clinical examination,
– Physical indicators
• Trauma of head, face, neck, hands. 50-75% of all physical
trauma occurs in the area of head and neck
– Behavioral indicators

52. PHYSICAL INDICATORS

53. • Clinical examination:
– Location of injury
• ‘safe triangle’
• Trauma on both sides
• Physical signs of injury: bruise, black marks, abrasions,
lacerations, burns, bites, eye trauma and fractures.
– Recognition of abusive bruises/ marks
• Colorimetric scale

54. Intraoral signs:
• Forked frenum
• Petechiae and scars on lips
• Lacerations on lips/ tongue
• Jaw fractures
• Avulsions of teeth
• Multiple root fractures
• According to Naidoo et al.abuse is most frequently located on
the oral structures such as lips (54%), followed by oral
mucosa, teeth,gingiva and tongue.

55. ABUSER CHARACTERISTICS
• Child abuse occurs in all cultural, occupational, socio economic and
ethnic groups.
• A proportionately higher incidence of abuse is reported in minority
and low in come families.
• Many parents or caretakers who abuse their children have an unusual
self-image, often low self-esteem.
• They may feel unloved, unwanted, and frustrated that their own needs
are not being met.
• Severe stress may have arisen because of marital and emotional
conflicts or financial problems.
• The abuser’s relationship with others is often characterized by tension
and a lack of trust.
• Abusive parents and caretakers may view the child as different or bad.
• Most important, the majority of abusing parents themselves have
experienced deficient childhoods.

56. ROLE OF PEDODONTIST
•By providing continual care, dentists are in a unique
position to observe parent child relationship as well as
changes in child’s behaviour.
•At Reception:
•Routinely observe children for unusual behaviour. Evaluate
hygiene, outward signs of proper nourishment, clothing
and general health.
•Check for any wounds or bruises in chilld’s face or body.
•Evaluate how child respond to others.

57. •Extraoral examination:
•Head and neck: asymmetry, swelling, bruising.
•Scalp: signs of hair pulling
•Ears: scars, tears and abnormalities.
•Bruises/ abrasions or varying colour, which indicates different stages
of healing.
•Distinctive pattern marks on skin left by objects.
•Middle third of face: bilateral bruising around the eyes, petechiae in
sclera of the eye, ptosis of eyelids or deviated gaze, bruised nose,
deviated septum or blood clot in nose.
•Check for bite marks: especially in areas that cannot be self-inflicted.

58. •Intra-oral examination:
•Burns/ bruises near commissures of the mouth: indicate gagging
•Scars on lips, tongue, palate or lingual frenum: forced feeding
•Labial frenum
•Hard tissue injuries: fractured/ missing tooth/ jaw fractures

59. •Legal aspects:
•Dentists should know the definitions of child abuse and
existing related laws proposed under the Draft Model
Child Protection Act 1977, to protect himself and apply it
correctly in such cases.
•Informing the parents,
•“Based on my training, I am concerned that this injury
could not have happened this way. Because of this, I am
required by law to make a report to childprotection
services.”

60. REPORTING CHILD ABUSE TO THE
AUTHORITIES
•Various Child care authorities and helplines all over the world.
•In US, National Child Abuse Hotline : 1-800-422-4453
•India: CHILDLINE 1098
•PANDA: Prevention of Abuse and Neglect through Dental
Awareness, active in North America 1992

61. LAWS IN INDIAN LEGAL SYSTEM
•In India, there is not a single law that covers child abuse in all
its dimensions.
•The Indian Penal Code (IPC) neither spells out the definition of
child abuse as a specific offence; nor it offer legal remedy and
punishment for it.
•In Indian legal system, the child has been defined differently in
the various lawspertaining to children.
Therefore, it offers various gaps in the legal procedure which is
used by the guilty to escape punishment.

62. CURRENT MEASURES TO PREVENT
CHILD ABUSE IN INDIA
•The Protection of Children from Sexual Offences Act and Rules, 2012
•Section 19(1)
•Section 19 (7)
•Rule 4 (3)
•The Juvenile Justice (Care and Protection of children) Act 2000 and
Delhi Rules 2009- Specific preventive provisions
•The Right of Children to Free and Compulsory Education Act, 2009
•The Integrated Child Protection Scheme
•Adolescent Education Programme
•Guidelines for Eliminating Corporal Punishment in Schools

63. MANAGEMENT AND PREVENTION OF
CHILD ABUSE AND NEGLECT
•The cliical protocol for management includes
-Behaviour assesment
-General physical examination
-Intraoral examination
-Documentation
-Treating of orofacial injuries
-counseling

64. • Behaviour assessment
• Speight in 1989 has given 6 classical points for assessment of
an abused child
 A delay in seeking medical help
 Details of the incident are vague
 Account of the accident is not compatible with the inury
observed
 The parents mood is abnormal
 Parents behaviour gives a cause for concern
 Child’s interaction with the parents is abnormal

65. COUNSELING THE ABUSED CHILD
• The way to effective counseling is
• Provide security
• Provide affirmation
• Provide a sense of bonding
• Provide intimacy and friendly enviroment

66. •Family counselling and education:
Reduce the impact of child abuse and develop strategies of
personal safety and protective healthy ways of children and
young people.
•Educate parent and focus on enhancing behaviour, such as
developing and practicing positive discipline techniques and
learning age-appropriate child development skill (Parent
Education Programs)

67. Management with Multidisciplinary
Approach
• With any instance of suspected abuse, it is crucial to
involve professionals with experience in dealing with
child maltreatment.
• Many medical centers now have child protective service
teams that include pediatricians with training in child
protection, psychologists, social workers and law
enforcement agents.
• The interdisciplinary approach of such a team allows for a
thorough assessment of the child and family.

68. conclusion
• At least 50% of the signs of physical child abuse manifest in
the orofacial region, this suggests that dental surgeons are in
an ideal position to alert child protection agencies about
possible abuse.
• Indeed, dentist may be the first group of professionals, or only
healthcare workers to see an “at risk” child, especially if they
are attending either for a routine check or because of dental
trauma.
• There are numerous reports in the literature where the dentist
was the initial professional to suspect nonaccidental injury.

69. References
• 1) Shobha Tandon’s textbook of Pediatric Dentistry
• 2) Nikhil Marwah’s textbook of Pediatric Dentistry